Medical Records Technician (Coder) Auditor (Inpatient/Outpatient and Physician)

Full Job Description

Located in the Healthcare Analytics and Management Department under the Chief of Staff Office at the MGVAMC.

MRTs (Coders) are skilled in classifying medical data from patient health records in the hospital setting and/or physician-based settings. Assign alphanumeric codes for each diagnosis and procedure.

Must possess expertise in the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Coding System (HCPCS).

To qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement.

Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Experience and Education: Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.

OR Education: An associate's degree from an accredited college or university recognized by the U.S.

Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding.

The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S.

Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

The following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses.

Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S.

Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures.

Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC.

Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers.

An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment.

At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations: Medical Records Technician (Coder) Auditor, GS-9 Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder).

Certification: Employees at this level must have a mastery level certification.

Assignment: For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time.

Auditors must be able to perform all duties of a MRT (Coder). Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding.

Auditors perform audits of encounters to identify areas of non-compliance in coding. They facilitate improved overall quality, completeness, and accuracy of coded data.

They provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements.

They assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.

They provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

They directly consult with the clinical staff for clarification of conflicting or ambiguous clinical data.

They use computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes.

They perform prospective and retrospective coding audits and use results to identify documentation, coding inadequacies, and re-educate clinical and coding staff based on audit results.

They act independently to plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports.

They assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality of clinical, financial, and administrative data.

They ensure that all coded data is fully documented and supported. They maintain statistical database(s) to track the results and validate the program.

They identify patterns and variations in coding practices with regular reports to the medical staff and management.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined).

Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.

Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements.

Ability to format and present audit results, identify trends, and provide guidance to improve accuracy.

Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

Preferred Experience: Experience in reviewing clinical documentation and developing strategies for improving coding accuracy and compliance.

Ability to mentor and train colleagues in data interpretation and the use of analytical software tools.

Knowledge of VERA program requirements and experience coordinating provider documentation education with the VERA coordinator.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-9.

Physical Requirements: Light lifting and carrying (under 15lbs), use of fingers, walking, standing, repeated bending, near vision correctable at 13" to 16" to Jaeger 1 to 4, far vision correctable in one eye to 20/20 and to 20/40 in the other, ability to distinguish basic and shades of colors, hearing (aid may be permitted), repetitive typing, and sitting long periods.

Environmental factors are working closely with others and alone. Major Duties:

Total Rewards of a Allied Health Professional Basic Functions Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, as well as the principles and practices of health services and organizational structure to ensure proper code selection.

Reviews assigned codes from the current versions of several coding systems, including the latest International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).

Adheres to accepted coding practices, guidelines, and conventions when selecting the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code.

Applies guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program.

Monitors evolving regulatory and policy requirements affecting coded information for the full spectrum of services provided. Timely compliance with coding changes is crucial.

Assists facility staff with documentation requirements to fully and accurately reflect the care provided; provides technical support regarding regulations, policies, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

Expertly searches patient records to find documentation justifying code assignment, based on an in-depth understanding of the organization and structure of patient health records.

Uses a variety of computer applications in daily activities. Specific Functions Reviews, analyzes, and reports performance measures for PTF, PCE, VERA, and Non-VA Medical Care (purchased care) coding.

Performs audits of ICD-10-CM and ICD-10-PCS codes, MSDRG, POA status, and discharge disposition values for inpatient health records.

Audits accurate and complete assignment of ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for both inpatient and outpatient records.

Reviews coding and assists coders and physicians in improving accuracy; provides coding guidance to staff at all levels to promote consistency and adherence to rules and regulations; initiates reporting and analyzes data.

Facilitates improved overall quality, completeness, and accuracy of coded data.

Responsible for performing audits of coded data, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating findings.

Collaborates with coding staff and clinical staff to support and educate on coding issues.

Assists in developing guidelines for data quality, consistency, and compliance monitoring to improve the integrity of clinical, financial, and administrative data, ensuring all coded data is fully documented and supported.

As a technical expert in health information coding, offers advice and guidance on documentation and coding requirements.

Analyzes audit results and prepares summary feedback for individual coders and clinicians, offering recommendations for improvement.

Maintains statistical databases to track results and validate the program, identifying patterns and variations in coding practices, with regular reports to staff and management.

Work Schedule: Monday-Friday, 8am-4:30pm Compressed/Flexible: May be available Recruitment Incentive (Sign-on Bonus): Not authorized Permanent Change of Station (Relocation Assistance): Not authorized Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not available Remote: Subject to change based on the agency's final work setting disposition for the series Functional Statement #: 70710-F Permanent Change of Station (PCS): Not authorized